The purpose of this video is to really focus on the standard techniques of dissection going through all the layers of the vaginal wall to minimize the chance of any erosion. The surgical case we're about to demonstrate involves the use of transvaginal mesh for reconstructive pelvic surgery. The patient is 88 years of age and presents with a several year history of pelvic organ prolapse. On a pop cue, it's a stage 3C. You can see that the cuff, she's status quo hysterectomy, and descends past the entoital opening by about 3 to 4 centimeters. So we place two Allis clamps on the anterior vaginal wall for downward traction. And you can also reach up with your fingers and just gently pinch and slide down and actually feel the bladder slide through your fingers. And then once you can feel that, you can actually displace the bladder back up a little bit, sort of potentiating the space. Now the space is a potential space. It's like a balloon with little to no air in it. So we're going to try to insufflate that space with fluid or hydrodissection. So what I brought onto the field here is a special needle. It's a TUI needle. A lot of people recognize it from the OB wards with epidurals. So the needle has a rounded tip rather than a cutting tip, so it gives you a popping sensation as it goes through layers. Also you can see that there's gradations here that are colored silver, black, silver, black. So you have a visual once you have the needle placed precisely where you'd like so you don't have any drifting. So again, downward traction of the anterior vaginal wall, a finger displacement. Now what I'm going to look for, and again, we know that it's going to be about a 5 to 7 millimeter advancement of the needle. So I sort of have a visual appreciation of how far I'm going. I'm also going to have some haptic feedback. So the needle goes in, and I can feel the popping. Now what I want to feel is very little pressure on the syringe, and you can see bilateral and symmetrical blebbing or infiltration, and I don't see any blanching of the anterior vaginal wall. If I was to get high resistance and blanching, then the bevel's in the vaginal wall. If I get, again, no blanching, no resistance, but yet no blebbing, there's a good chance that the bevel's actually in the bladder. So what we want to see is what we're seeing here is no resistance on my thumb, blebbing, bilateral and symmetrical, with no blanching. So I come back in with a standard needle, which will push fluid, go into 5 millimeters, and keep the needle shaft parallel to the vaginal wall, and again, it's kind of forcefully inject fluid in that direction where we will be dissecting, and I put 10 cc's onto each side. You will notice some return of the fluid coming back out your hole, which usually isn't significant. Again, back into 5, keeping the needle shaft parallel to the vaginal wall, and then infiltrating. Then we need to incise our anterior vaginal wall. I tend to like electrocautery for this, but scalpel is fine. And again, just like we're entering a peritoneal cavity, we're going to go very slowly, layer by layer, until we reach our proper depth. We're going to be looking forward to seeing a gray bevel, or I should say, bubble. It's a fluid-filled sac that we've just created. So now you can start to see this grayish, fluid blebble here, and we're going to move up, so you can call it a bleb or a bubble, I guess either one. What I like to do is use a pair of nets to get behind that vaginal wall, and I actually prefer a very sharp net, so I see a tenotomy-type scissors. What I'm going to do is, again, just develop the space here, because it, again, is very clearly demarcated, so there's not any digging. With transvaginal mesh repair, again, we need to go deeper through the epithelium, through the lamnia propria, the muscularis, and then the connective tissue. One of the things you're starting to see right here is some fat. Now we'll see this fat as well in the true vesicle-vaginal space, but I also think here we may be a little pre-peritoneal, and this lady may have a bit of an anterior anteroseal, which are relatively uncommon, but we'll see the peritoneum coming down. But the fat is always a very good sign, because you know you're truly in a space. Gross fat like that does not exist in the bladder wall nor the vaginal wall. So again, full thickness dissection is absolutely paramount in order to get proper mesh placement to minimize erosion. Now we're working our way up here towards the UBJ. So now we're going to start dissecting laterally, and I will use a pair of Atsins for counter-traction and use the Sharp Mets to develop this plane right between the vaginal wall and, again, the fluid bubble that we've developed. This is probably, again, a bit of an anterior anteroseal element, it's a little bit bigger than we're used to dealing with right off the bat. So I'm going to switch over quickly to using a four-by-four on my fingers as counter-traction as opposed to an Atsin. The Atsin works best when you're only counter-tracking a small amount of tissue. Again, the bladder's here, and people tend to get a little nervous that it's so close to you, but again, you know exactly where it is, and it's not as close as you think because of that fluid we've put in. It gives us a little bit of a cushion, a little bit of breathing room here, so you don't think that your slightest little move, you're going to make a nick into the bladder wall. Now that we're starting to move out of my very clear plane line of sight here, where I can't really keep my eye on those tips of these fairly sharp scissors, I'll switch these out for more standard dolphin-tip Metsabon scissors so they don't do any damage. So now what I'm doing is just pushing close with the Mets, opening, and then dragging back, creating, again, a sharp space between the vaginal wall and the bladder. Now once you have that, you want to index finger and let your assistants go in with the alices, because as my pressure goes in laterally, I'd want to be in the pelvis, not out here. So if your assistants are pulling back on you, then you're not going to be able to do the proper blunt dissection, so we let it drift in, we call it. Now I'm going to push in and sweep down. I'm going to develop this sort of pericopium sock, a little space, if you will, in the loose areola connective tissue laterally, going down towards the ischial spine. So now you have this nice and cleaned off now, I can sweep here and get it very crisp. Sometimes you're in here and you'll get a little veil of connective tissue that'll be over your finger, and that'll just be a little bit problematic when you go to deliver your Mets system. So we try to get it as crisp as possible, and just patience with rubbing, firm, sometimes use the ischial spine as a backstop, so I'll rub my finger sort of in a circular motion. We'll come out here and just sort of look for any paravaginal bleeding, you can see some there, and that's from the paravaginal veins, because usually if it gets kind of wet, we'll go ahead and pack that. But what I was doing inside was that that's the ischial spine, I'm rubbing forcefully against it and around and around to actually help burrow through that areola tissue. So now we're going to go to the other side, again, the same thing we're going to see here, sort of counter traction, this time, again, since we have such a large dissection going already, meaning that we've got good exposure here, then you're better off using your hand in a 4x4, and very often instead of pushing in, which makes it hard for me to see the plane, I can't really see the edge there of where I want to dissect, I actually want to pull out and over, and by pulling out and over, I'm actually going to see where I want to be with my scissors better, so out and over is going to help me see the exact spot I want to be in for the dissection, and again, sort of a plastic sharp dissection, a little snip and then a spread. What I'll do is have a fold in here throughout the case, I'll give it a little tug in order to get a better awareness of the lower urinary tract, and again, sort of that pill rolling down sideways here, developing the paravesical, and very often people will say the paravaginal space, but as well as up into the paravesical space. This is opened up nicely on this side, now I can see again the ischial spine here, rubbing my finger, feeling the obturator internus muscle, the arcus is going this way, deep towards here, you can feel that as very often as sort of a rope-like band, and you can feel all those. If you reach out, you can easily always feel the obturator canal with the nerve artery and vein going through it, which is again an important landmark. Again, we're going to check for any bleeding, you can see as I pull my finger back, even displace it, no venous bleeding on this side. Now we're going to also mobilize until we get to the cuff, which is our proximal attachment or attacking side of the mesh, and then at the urethra-vesicle junctions, again going to a more blunt dissection. You can see the bright white here, and there's the fluid, and you can see grossly the pre-peritoneal fat here, and then as you go up higher, that is actually vesicle, vaginal space, and paravesical fat next to the cirrhosis of the bladder. Again, you see gross fat like this, you know you're in a true space. This fat that you can see across the room does not exist in the vaginal wall, nor does it exist in the bladder wall, so it's an affirmation you're in a true space.

surgical procedure

transvaginal mesh

reconstructive pelvic surgery

pelvic organ prolapse

dissection